TRANSSTERNAL REPAIR OF COARCTATION AND ASSOCIATED CARDIAC DEFECTS

Over a 13-year period, 20 infants and children underwent transsternal approach for repair of coarctation and associated cardiac defects. Fif teen patients (75%) were operated on in the last 6 years. Thirteen pat ients (group 1) had intracardiac shunts and 7 (group 2), intracardiac obstruction or valvular insufficiency. Group 1 had a mean age of 0.8 /- 1.9 years versus 4 +/- 3 years for group 2 (p = 0.05). There were 1 2 patients (92%), 7 months old or less in group 1. Aortic arch hypopla sia was present in 6 patients in group 1. A large patent ductus arteri osus was present in 5 of these 6 patients versus no patent ductus arte riosus in patients without aortic arch hypoplasia (p = 0.006). The mea n pulmonary blood now to systemic blood flow ratio in group 1 was 3.8 +/- 2 and the mean right ventricular to left ventricular ratio, 0.8 +/ - 0.2. The coarctation repair fell mostly into three types: side patch aortoplasty (8), ductal tissue excision and patch aortoplasty of the concavity of the aortic arch (6), and subclavian aortoplasty (4). Ther e was one early death (5%) which was due to sepsis in a newborn. Anoth er newborn who had subclavian aortoplasty needed a left carotid artery -descending aorta bypass conduit early because of aortic arch hypoplas ia. All patients were followed to 12 years (mean follow-up, 4.3 +/- 3. 5 years). There were no late deaths. Two patients had recurrent coarct ation, 1 after an end-to-end repair and the other because of incomplet e arch enlargement after a side patch aortoplasty. We conclude that a transsternal approach, which minimizes incisions and reoperations, can be safely accomplished in infants and children to repair coarctation and associated cardiac defects. Although most coarctation repair techn iques could be performed, ductal tissue excision with patch aortoplast y of the concavity of the arch appears simple and provides an excellen t option for complete relief of obstruction, unhampered aortic growth, and probably reduced aneurysm formation.